Airside Operations Safety: Understanding the Effects of Human Factors (2022)

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80 Human Factors Investigation Guide The purpose of this appendix is to provide those who investigate incidents in the airside environment information that may improve the quality of the data collected on the human factors involved. This appendix is not an exhaustive guide on how to conduct a safety investiga- tion. Its focus is on improving the quality of the human factors portion of an investigation and on assisting those without formal training in investigative techniques in capturing information that will lead to the root causes of an incident. The appendix is presented in three parts. Part 1 provides effective practices for those assigned to lead an interview. Part 2 is a checklist an investigator can use to ensure the important human performance elements are explored during an investigation. Part 3 contains investigation train- ing resources. B.1 Part 1 Overview: Keys to Conducting an Effective Investigative Interview When investigating the human factors of an incident, the key pieces of information will come from interviewing the people involved. This information can be used to prepare for interviews or practice the techniques when training those who may be assigned investigation duties. This guidance is adapted from Boeing’s Ramp Error Decision Aid (REDA) User’s Guide. The REDA tool is a structured process developed by Boeing and made available to the aviation industry for the purpose of effectively investigating events where worker performance may be a cause. This information presents considerations and techniques an investigator may employ to enhance interviews for the purpose of capturing as much information as possible on the human factors involved in an event. B.2 Part 2 Overview: Investigation Checklist for Human Factors This checklist is intended to provide investigators with a single page (front/back) that can be taken into the field and used as a guide for capturing key human factors information related to a V/PD or any safety incident that might occur at an airport. The checklist is adapted from two investigative tools – Boeing’s REDA Form Revision M (February 12, 2016) and the Department of Defense Human Factors Analysis and Classification System (DoD HFACS) Guide, Version 7.0, Revision 01. A P P E N D I X B

Human Factors Investigation Guide 81   B.3 Part 3 Overview: Investigation Training and Education Resources Airports desiring to train one or more staff members as lead safety investigators have a number of education and training resources available. Part 3 provides information on a number of organizations that have investigations training either as a standalone course or integrated into the curricula. This is not intended to be an exhaustive list; it is simply designed to serve as a starting point for airports exploring options for investigations and human factors enhance- ment. Airports located near a university that has an aviation degree program may find success in contacting that school directly. B.4 References REDA and the DoD HFACS Guide in their entireties are available to the public. The REDA User’s Guide and the REDA Results Form can be found by going to the FAA Human Factors in Aviation Maintenance website, the Library and Current Research page, and then searching for “REDA” (https://www.faa.gov/about/initiatives/maintenance_hf/library/?q=REDA&bSubmit= Search). The DoD HFACS Guide 7.0 is available in PDF form on the Air Force Safety Center website: https://www.safety.af.mil/Divisions/Human-Factors-Division/HFACS/. Additionally, the Naval Safety Center provides the guide on its mobile app, thus making it an easy reference for HFACS definitions, codes, and investigative questions while in the field. The app is available using the app store on mobile devices and searching for “Naval Safety Center.” B.5 Part 1 – Keys to Conducting an Effective Investigative Interview B.5.1 General Principles of Investigative Interviewing • Develop and maintain good rapport with the person to be interviewed. – Use a neutral tone in the voice and relaxed body language. – Question and listen. Avoid arguments, judgmental comments, and criticism. • Encourage the interviewee to be actively involved – have a discussion. – Make it clear that they have the information and the answers, and therefore will be doing most of the talking. – Explain that you would like interviewees to volunteer information whenever they think of it. They should state things in their own words and at their own pace. – Strive to get as much detail as possible, but ensure that the interviewee does not guess or make up answers. • Help the interviewee concentrate. Conduct the interview in a quiet setting without dis- tractions, and ask questions on the same topic before moving on to another topic. • Ask open, simple, and unbiased questions. This allows the interviewee to recreate the incident in the form of a story. – Begin with broad, open-ended questions, followed by focused or narrowly scoped questions on a particular issue to capture important details. – Only use closed questions to fill in missing details undiscovered through open questions. – Avoid questions that lead the interviewee.

82 Airside Operations Safety: Understanding the Effects of Human Factors – Ask one question at a time. – Example broad question: “Where were you on the airport, and what were the conditions at the time?” – Example narrow questions: “With whom were you communicating? Were you communi- cating using a radio?” – Example closed question: “Were the responses from the tower clear, weak, or garbled?” – Example leading question: “In the light rain and fog, was it very difficult to see the sign?” • Listen actively to interviewees and show them you are interested in what they have to say. – Do not interrupt interviewees unless they stray considerably from the topic. – Give feedback to indicate that you are listening, such as nodding and asking confirming questions. – Write down additional questions you think of during the interview. • Use a communication style to suit the interviewee. Use familiar terms and ask simple questions to help the interviewee build up confidence. • Decide on the number of people to be present during the interview. – One person is the least threatening, but that person needs to be an experienced interviewer. – Two-person teams work well, where one conducts the interview and the other records the information. – If the person being interviewed is a union member, a union steward may be present. • Encourage the interviewee to write down details of the event as soon as conveniently possible. Allow the interviewee to use props or draw out the event to provide more information and details. B.5.2 Pre-Interview Preparation and Planning • Before carrying out the interview, gather as much information as possible about what happened. Go into the interview with knowledge of the event that started the investigation. Before interviewing, obtain additional background information. This information may include: – What were the situational and environmental conditions at the time of the event? Visit the site at the same time of day the event took place; examine any equipment involved to put the event into context. – What documented policies, procedures, rules, and regulations were in place related to the conduct of the activities leading to the event? Were any procedures performed incorrectly that led to the event? – What background information is available regarding the interviewee? How many years of experience does the worker have at the airport and in the industry? On the specific task? On operated equipment? • Determine the aims of the interview and types of information sought. • Determine the location of interview. Choose an area that is quiet so that you can talk easily with the person. – Find a place where all participants can sit down to carry out the interview. It should be a place where the interviewer and the interviewee can talk as two people on an equal level. Pick a neutral location like a private room or a quiet corner that is free from distractions. – Do not carry out the interview with the investigator sitting behind a supervisor’s desk and the interviewee sitting in a chair in front of the desk. This could create a perception of inferiority (employee versus supervisor), and the interview could start to feel like an inter- rogation or cross-examination. B.5.3 Conducting the Interview • Introduction. Begin by introducing yourself to the interviewee and telling the person the reason for the interview.

Human Factors Investigation Guide 83   • General account of event. Ask the interviewee to recreate the general context of the event. – Example opening statement: “What I would like is for you to tell me the sequence of events as you saw them. Start from wherever you think is relevant. Tell me everything that you can remember, even the things that you think are not important and even if you cannot remember something completely.” • Detailed account of parts of the event/task. Ask that the interviewee provide additional details on specific issues about the event. These issues could come from the pre-planning or be based on information provided by the interviewee. – Example statement: “We would like to get some more information and clarify some issues. I would like to start when you were . . .” (e.g., first contacting the tower for clearance). • Detailed information about the potential contributing factors. During the interview, infor- mation will come out that will appear to uncover causes of the event. Revisit and explore those factors. – Example question: “I think I heard you say that you were having trouble understanding the tower due to aircraft engine noise. Is that accurate?” • Keep asking “why” (open-ended questions) until you reach a natural stopping point. • Ask interviewees how they would improve the causal factors to prevent future incidents. – Background information. Obtain information that will help evaluate the interviewee’s ability to assess the events they described, such as operational experience of persons involved or knowledge levels on the assigned tasks. • Conclusion. Clarify any discrepancies and ask interviewees if they have anything else to add.

84 Airside Operations Safety: Understanding the Effects of Human Factors B.6 Part 2 – Investigation Checklist for Human Factors I. Event Human Factors Contributing Factors Collection A. Information (e.g., written procedures, airport rules and regulations, signage, airport markings) __ 1. Not understandable __ 5. Insufficient information __ 9. Inefficient procedure __ 2. Unavailable/inaccessible __ 6. Update process is too long/complicated __ 10. Uncontrolled __ 3. Incorrect __ 7. Incorrectly modified guidance __ 11. Other (explain below) __ 4. Too much/conflicting information __ 8. Information not used B. Equipment (e.g., vehicle, tools, safety equipment, communications) (Note: PPE/CPE = personal protective equipment/collective protective equipment) __ 1. Unsafe __ 8. Cannot use in intended environment __ 15. PPE/CPE unavailable __ 2. Unreliable __ 9. Incorrectly used in existing environment __ 16. Out of calibration __ 3. Layout of controls or displays __ 10. Too complicated __ 17. No instructions __ 4. Not used __ 11. Incorrectly labeled/marked __ 18. Inaccessible __ 5. Unavailable __ 12. Not labeled/marked __ 19. Past expiration date __ 6. Inappropriate for the task __ 13. PPE/CPE not used __ 20. Other (explain below) __ 7. Incorrectly used __ 14. PPE/CPE used incorrectly C. Job/Task (aspects of the task/event that impact performance) __ 1. Repetitive/monotonous __ 4. Different from other similar tasks __ 7. Physically challenging __ 2. Complex/confusing __ 5. Requires forceful exertions __ 8. Long duration __ 3. New task or task change __ 6. Requires kneeling/bending/stooping __ 9. Other (explain below) D. Knowledge/Skills __ 1. Technical skills __ 4. English language proficiency __ 7. Teamwork skills __ 2. Task knowledge __ 5. Airport process knowledge __ 8. Supervisory skills __ 3. Task planning __ 6. Communication skills __ 9. Other (explain below) E. Individual Factors (when possible, investigate the 72 hour history of the individual(s) involved) __ 1. Physical health (including __ 5. Complacency __ 10. Visual perception hearing and sight) __ 6. Body size/strength __ 11. Assertiveness __ 2. Fatigue __ 7. Personal event (e.g., family problem, car accident) __ 12. Stress __ 3. Time pressure __ 8. Task distractions/interruptions __ 13. Situation awareness __ 4. Peer pressure __ 9. Memory lapse (forgot) __ 14. Workload/task saturation __ 15. Other (explain below) F. Environment/Facilities/Airfield __ 1. High noise levels __ 6. Snow __ 11. Hazardous/toxic substances __ 16. Lighting __ 2. Hot __ 7. Wind __ 12. Power sources __ 17. Labels/placards/signage __ 3. Cold __ 8. Lightning __ 13. Inadequate ventilation __ 18. Confined space __ 4. Humidity __ 9. Vibrations __ 14. Inadequate blast protection __ 19. Other (explain below) __ 5. Rain __ 10. Cleanliness __ 15. Markings G. Amplifying Information (Details on specifically how the selected factor(s) contributed to event.) (Use additional pages as necessary) N/A __ N/A __ N/A __ N/A __ N/A __ N/A __

Human Factors Investigation Guide 85   II. Guiding Human Factors Questions for Investigations/Interviews (HFACS Based) A. Acts (Active Failures or Actions) Questions __ 1. Did anyone make a performance-based error? __ 2. Was anyone’s action the result of poor judgment or decision making? __ 3. Did anyone violate a commonly known law or regulation? B. Preconditions Questions __ 1. Was the environment a factor in the event? __ 2. Did the physical environment affect the person(s) involved? __ 3. Did the technological environment affect the person(s) involved? __ 4. Did the mental, sensory, or physical state of the person(s) involved contribute to the event? __ 5. Did the person(s) involved have a medical or physical condition? __ 6. Did the state of mind of the person(s) involved create an unsafe situation? __ 7. Was sensory information misperceived or misunderstood? __ 8. Did the mental awareness of the person(s) involved create an unsafe situation? __ 9. Did challenges with teamwork contribute to the event? C. Supervision Questions __ 1. Did supervision or supervisory policies contribute to the event? __ 2. Did a supervisor violate a commonly known law or regulation? __ 3. Did supervision fail to plan or assess known hazards? __ 4. Did a supervisor or supervision prove inadequate? D. Organizational Influences Questions __ 1. Did the airport or other stakeholder organizational policies contribute to the event? __ 2. Did a problem with resources create an unsafe situation? __ 3. Was selection or staffing of personnel a factor? __ 4. Did an airport or other stakeholder rule, regulation, or policy create an unsafe situation? __ 5. Did the safety climate/culture contribute to an unsafe situation? III. Summary Summary of the human factors, additional details, and added context to the event (Use additional pages as necessary) N/A __ N/A __ N/A __ N/A __

86 Airside Operations Safety: Understanding the Effects of Human Factors Organization Website Duration Attendance Location Cost ($) Course Description Air Line Pilots Association (ALPA) https://www.alpa .org/news-and- events/meetings- training/trainings -details/courses/a aic 4 days In-person Grand Forks, ND $1,000 Accident investigation course and advanced accident investigation course lead the Master Executive Council (MEC) accident investigator through a complete simulated accident while maintaining a balance of academic application and realistic simulation. Non-ALPA members need to be approved, and course may include a $1,000 registration fee to attend. Embry-Riddle Aeronautical University https://erau.edu/d egrees/aviation https://daytonabe ach.erau.edu/deg rees/professional -programs Multiple options Online and in-person Daytona Beach, FL Prescott, AZ $447/credit hr. ERAU's Professional Education Solutions program offers seminars and a certificate program, including aircraft accident investigation, designed to provide insight into the role of an accident investigator from theory to practical application. FAA https://www.faa. gov/about/initiati ves/maintenance _hf/library/docu ments/media/hfa cs/2_accidentinv estigation.pdf 1.5 hours N/A N/A N/A Accident investigation PowerPoint created to be a generic guide for responding to aviation organization accidents. FAA https://www.aca demy.jccbi.gov/c atalog/ Varies Varies Varies Varies Search engine of the FAA catalog of training. Database of courses offered through various vendors. International Air Transport Association (IATA) https://www.iata. org/en/training/c ourses/airline- safety- investigation- virtual/talp25/en/ 4 days Online N/A > $2,000 Airline safety investigation (live virtual classroom). Learn how to participate in an aircraft accident and serious incident investigation, in accordance with ICAO Annex 13 standards. NTSB Training Center https://www.ntsb .gov/Training_C enter/Pages/Trai ningCenter.aspx 12 days Online and in-person Ashburn, Virginia $1,000– $4,000 Aircraft accident investigation provides participants with a comprehensive overview of the procedures and methods used and the skills required to investigate an aircraft accident. B.7 Part 3 – Investigation Training and Education Resources

Human Factors Investigation Guide 87   Southern California Safety Institute (SCSI) https://scsi- inc.com/Home 2 weeks Online and in-person Redondo Beach, CA $2,500– $3,600 Stand-alone classes as well as a certificate in aircraft accident investigations that includes its Accident Investigation Crash Laboratory. Online versions offered. Any of SCSI’s course offerings can also be tailored and delivered at a location and time of choice. Southern California Safety Institute https://www.scsi -inc.com/HFAI 4 Days Online and in-person Los Angeles, CA $2,500 Human Factors in Accident Investigation: This course provides an integrated discussion summarizing from an investigator’s perspective current understanding about causes of human errors and what mechanisms should be in use for their reduction. Transportation Safety Institute https://tsi-dot. csod.com/LMS/ catalog/Welcome. aspx?tab_page_ id=-67&tab_id =20000328 1–2 weeks Online and in-person Oklahoma City, OK $1,000– $3,000 Home to the National Aircraft Accident Investigation School. Training in aviation safety, accident investigation techniques, and safety management through workshops, field activities, individual studies, and hands-on training. University of North Dakota (UND) https://aero.und.e du/aaic/ 2.5 days In-person Grand Forks, ND Variable UND Aerospace offers an aircraft accident investigation course. This hands-on course, using a Boeing 727 aircraft, provides participants experience with the logistics involved in accident response, participating in on-scene groups, and on-scene investigative techniques. University of Southern California Viterbi School of Engineering https://aviationsa fety.usc.edu/cour ses > 2 weeks Online and in-person Los Angeles, CA $1,000– $5,000 Many courses on responding to and conducting aircraft accident investigations. Geared toward management/safety personnel involved in planning, response, or recovery from accident/incident situations.